Nurse Practitioner Clinical Protocol: Management of Cellulitis Cellulitis:

Transcription

Document Ref
October 2011
Page 1 of 11
Nurse Practitioner Clinical Protocol: Management of Cellulitis
Cellulitis:
An acute spreading bacterial infection below the surface of the skin characterized by redness (erythema), warmth, swelling, and pain.
Cellulitis can also cause fever, chills, and "swollen glands" (enlarged lymph nodes). Cellulitis is a clinical diagnosis based on the spreading involvement of skin and subcutaneous
tissues with erythema, swelling, and local tenderness, accompanied by fever and malaise.
Cellulitis commonly appears in areas where there is a break in the skin from an abrasion, a cut, or a skin ulcer. It can also be due to local trauma, such as an animal bite. Only rarely
is Cellulitis due to the bacteremic spread of infection -- bacteria arriving from a distant source via the bloodstream.
Extreme complications of untreated Cellulitis can result in :
•
•
•
•
•
•
•
Blood infection (septicaemia)
Bone infection (osteomyelitis)
Inflammation of the lymph vessels (lymphangitis)
Inflammation of the heart (endocarditis)
Meningitis
Shock
Tissue death (gangrene)
SCOPE OF PRACTICE
PRACTITIONER
Nurse Practitioner –
Aged Care
Medical Practitioner + Nurse
Practitioner
SCOPE
The NP will treat all residents in Bethanie Care Services who present
with symptoms presenting in this clinical guideline.
The scope of practice of the NP will be directed by:
The Nurses Act 2002 (WA)
The Nurses Rules 1993 (WA)
The Nurses Code of Practice 1995 (WA)
The Poisons Act 1964 (WA)

The NP will refer all Bethanie Group residents outside their scope of
practice to a medical practitioner.
OUTCOME

The expected outcome of use of this clinical guideline is
effective and rapid treatment, prevention of exacerbation
and reoccurrence of infection.
The prevention of hospital admission
Upon failure of treatment, complications of infection or
recurrence of infection, referral to a specialist wound care
service is required. 1 Referral to occupational therapist
and/or physiotherapist should be considered if lack of
mobility or function are contributing factors.
Cellulitis
Document Ref
October 2011
Page 2 of 11
RESIDENT’S ASSESSMENT
RESIDENT’S HISTORY
Presenting symptoms
INFORMATION
Signs and symptoms of Cellulitis in the elderly:
Cellulitis most commonly affects the lower extremities, although
symptoms can develop in any area of the body. The condition affects the
skin in several ways, causing it to become: red, painful, hot, swollen,
tender and or blistered
Cellulitis often causes the person to feel generally unwell, causing
symptoms that develop before, or in combination with, changes to your
skin. These symptoms include: nausea, shivering ,fatigue, chills, general
sense of feeling unwell and disorientation/confusion
Systemic Presentation often includes Raised temperature, occasionally
rigors and or raised white cell count
Certain host factors predispose to severe infection. Individuals with
comorbid conditions such as diabetes mellitus (frequently polymicrobial),
immunodeficiency, cancer, venous stasis, chronic liver disease, peripheral
arterial disease, chronic kidney disease, and other systemic disease appear
to be at a higher risk for both recurrent and more severe infection, owing
to an altered host immune response.
OUTCOMES
•
Collation of accurate clinical assessment data to
facilitate prompt treatment and prevent re-occurrence
•
Appropriate systemic and topic therapies are
prescribed and initiated taking into account the
individual medical history and presentation.
•
Prevention of exacerbation and or recurrence of
Cellulitis
Cellulitis
Document Ref
October 2011
Page 3 of 11
RESIDENT’S ASSESSMENT
RESIDENTS HISTORY
Known risk factors for the
presenting symptoms
Previous medical history
Medications
Other relevant information
PHYSICAL Ax
INFORMATION
Risk factors fall into several categories: disruption of the cutaneous
barrier (e.g. trauma, leg ulcer etc) venous or lymphatic compromise (e.g.
venous insufficiency, obesity, previous vascular surgery, pelvic radiation
or malignancy, previous tibial fracture. Previous history of Cellulitis.
Staphylococcus aureus and beta-hemolytic streptococci in the toe webs
are significantly associated with acute Cellulitis of the lower limb.
Previous vascular surgery/procedures to lower extremetities, previous
Cellulitis
Current Medications
Allergies, previous Cellulitis history, nutrition & hydration, skin
integrity, mobility, cognition and behaviour.
OUTCOMES
Prompt diagnosis and treatment will be initiated
Appropriate dressings and drug therapy will be initiated
INFORMATION
Usual physical examination
Record findings: temperature, pulse, blood pressure , respiratory rate
skin integrity assessment, wound assessment, pain assessment.
Indications for specific
examinations
Assess systems that may reveal fever with/without tachycardia,
lymphadenopathy, vascular streaking, mental status changes,
hypotension, decreased pulses & signs of deep vein thrombosis. Specific
focus on lifestyle risks, previous surgery, comorbid conditions: diabetes,
Peripheral vascular disease, peripheral arterial disease, heart failure, use
of immunosuppressive agents and potential sources of skin disruption:
ulcerations, fungal infection in the toe webs, punctures and animal bites.
OUTCOMES

Correct diagnosis, provision of effective disease and
symptomatic eradication/relief.
Documentation of infection incident via The Bethanie
Group’s clinical incident system
Cellulitis
Document Ref
October 2011
Page 4 of 11
INVESTIGATIONS
INDICATIONS
Routine investigations
INVESTIGATIONS
Laboratory/diagnostics used for diagnosis and identification of
organism: skin swab only if ulceration or exudate present.
Pathology
To determine underlying
organism, severity and sensitivity
of organism.
Wound/skin MCS
Imaging
Nil
Haematology/Biochemistry
If suspected pyelonephritis only
FBC, U&E
Other Investigations
Nil
OUTCOMES

Results from all investigations will be used when
determining future management of the residents.

Accurate diagnosis will be made.

Correct pharmacotherapy will be prescribed based on
sensitivity of organism.
Cellulitis
Document Ref
October 2011
Page 5 of 11
FOLLOW UP AND EDUCATION
INTERVENTION
INFORMATION
Pharmacotherapeutics
(See pharmacotherapy section)
The treatment chosen will be dependant on the organism believed to
have caused the infection, with consideration of the resident’s allergy
history, general medical condition, and renal and hepatic status, as well
as the degree and quality of infection. All may effect outcomes of the
resident’s hospitalization versus resident’s treatment. In the feet, topical
antifungals should be used in those with fissures, until healed.
Analgesics should be used as appropriate.
Consider increasing diuretic therapy if peripheral oedema is marked
Non-pharmacological
(including topical dressing
therapy)
Immobilization of the area with elevation (if in a limb) is important to
decrease pain and diminish oedema. Commence initial anti-bacterial
dressing such as cadexomer iodide dressing(iodosorb).If no response
within 24-48hrs(i.e cellulitic area increasing:commence silver dressing
such as Mepilix Ag/Atruaman Ag
Blood glucose levels in known diabetics should be regularly monitored
and managed. Consultation with a physician is recommended if
necrotizing fasciitis or an abscess is suspected, if cellulitis occurs in the
orbit of the eye, if there is a high fever or extreme pain, if the condition
does not respond to treatment, or if surgical debridement is required.
Hospitalization may be required if any of these instances.
Ensure area of demarcation is marked on skin with skin marker to
observe for exacerbation/improvement
Follow up appointments
Resident needs to be reviewed daily post commencing antibiotic therapy
to reassess symptoms and monitor for any complications or adverse
reactions to therapy. Follow up consultation is required to validate
eradication of infection and determine whether further antimicrobial
treatment is required. An evidence based care plan should be developed.
NPs are required to follow up on all referrals to allied health/specialists
and reinforce education and management strategies.
OUTCOMES

Eradication of infection

Prevention of exacerbation

Prevention of recurrence of infection

Management of oedema

Symptomatic relief

Underlying disease will be detected at follow up.

Upon failure of treatment, complications of infection or
recurrence of infection, referral to a medical practitioner
is required. Referral to occupational therapist and/or
physiotherapist should be considered if lack of mobility
is a contributing factor.
Cellulitis
Document Ref
October 2011
Page 6 of 11
FOLLOW UP AND EDUCATION
INTERVENTION
INFORMATION
Resident’s/staff education
Resident and their caregivers need to understand the importance of
completion of diagnostic and treatment plans. Completion of antibiotic
regimens is important to eradicate the infecting organisms and to
decrease the possibility of treatment failures, including organisms’
tolerance to antibiotics. Education regarding: possible medication side
effects and anaphylaxis; signs & symptoms of super-infection of the site,
DVT, systemic infection; and the importance of follow-up care is
needed. Control of oedema, elevation of the affected limb, and
minimization of trauma to the area should be taught. The resident or
caregiver should be able to demonstrate specific wound care. Signs and
symptoms that require immediate follow-up should be emphasized.
OUTCOMES

Optimise independence, awareness and education

Optimise compliance with treatment

Optimise eradication of infection and prevent recurrence
of infection.

Prevention of breaks to skin
Cellulitis
Document Ref
October 2011
Page 7 of 11
PHARMACOTHERAPY
The management of cellulitis can be divided into two distinct phases: Treatment directed at the acute celluitis, including the decision about hospitalization, and preventive therapy
to diminish the likelihood of subsequent bouts of cellulitis, particularly in residents who have had previous episodes in the same anatomic location.
Decision to hospitalize –
Most residents with cellulitis present with recognizable skin findings (erythema, skin indurations, edema, lymphangitis) and low –grade fever. For the occasional
resident with high fevers, rigors and other signs of systemic toxicity including mental status changes or even shock, the decision to admit the resident to the hospital is
recommended
1st line treatment for cellulitis flucloxacillin/cephalexin
Diabetics Cellulitis in the diabetic resident with a non-healing plantar foot ulcer usually requires broader spectrum coverage to include treatment of S. aureus, beta-hemolytic
streptococci, aerobic gram-negative bacilli, and anaerobes pending results of cultures and susceptibility testing: antibiotic therapy is a treatment option in these residents
but should be used first for Cellulitis in the absence of an ulcer. Diagnostic testing for accompanying osteomyelitis or abscess formation should be included in the
evaluation of diabetic residents with Cellulitis of the foot. Treatment Augmentin duo 1 tb bd
Cellulitis
Document Ref
October 2011
Page 8 of 11
PHARMACOTHERAPY (Cont..)
FORMULARY
Cephalexin
Amoxycillin with clavulanic acid (diabetic)
Drug (generic name): cephalixin 1st line
Drug (generic name): amoxicillin with clavulanic acid
Poisons Schedule: Schedule 4
Therapeutic class: 8(b) cephalosporins
Therapeutic class: 8(a) penicillins – infections & infestations
Dosage range: 250mg – 1g
Dosage range: 500-875mg
Route: oral
Route: oral
Frequency of administration: 6 hourly
Duration of order: variable
Duration of order: 5-10 days
Actions: intervenes in bacteria cell wall peptidoglycan synthesis
Indications for use: staphylococcal & streptococcal infections (when mild-moderate
Indications for use: hospital acquired pneumonia, UTI, epidiymo-corchitis, bites &
allergy to penicillin’s), susceptible gram negative bacterial UTI’s, epididymo-orchitis
clenched fist injuries, otitis media, acute bacterial sinusitis, acute cholecystitis,
Contraindications for use: allergy to penicillins, cephalosporins or carbapenems
melioidosis
Adverse drug reactions: nausea, diarrhoea, electrolyte imbalance, rash, rare:
cholestatic hepatitis
Contraindications for use: allergy to penicillins, cephalosporins or carbapenems.
Cholestatic jaundice or hepatic dysfunction associated with amoxicillin with Clavulanic
acid, or ticarcillin with Clavulanic acid.
Adverse drug reactions: transient increases in liver enzymes & bilrubin, cholestatic
hepatitis, rare: acute generalized exanthematous pustulosis
Cellulitis
Document Ref
October 2011
Page 9 of 11
PHARMACOTHERAPY (Cont..)
FORMULARY
Flucloxacillin 1st line
dicloxacillin
Drug (generic name): flucloxacillin
Drug (generic name): dicloxacillin
Dosage range: 250 – 500mg
Dosage range: 250-500mg
Route: oral
Route: oral
Actions: bactericidal, intervenes in bacteria cell wall peptidoglycan synthesis
Indications for use: staphylococcal skin infections including: folliculitis, boils,
Indications for use: staphylococcal skin infections including: folliculitis, boils,
carbuncles, bullous impetigo, mastitis, crush injuries, stab wounds, infected scabies
carbuncles, bullous impetigo, mastitis, crush injuries, stab wounds, infected scabies,
pneumonia, osteomyelitis, septic arthritis, septicaemia, empirical treatment for
Cholestatic hepatic associated with dicloxicillin or flucloxicillin
endocarditis, surgical prophylasis
Adverse drug reactions: transient increase in liver enzymes bilirubin, cholestatic
hepatitis
Cholestatic hepatic associated with dicloxicillin or flucloxicillin
Adverse drug reactions: transient increase in liver enzymes bilirubin
In the rare occurrence that the resident is allergic to both Penicillin and Cephalexin the alternate treatment would be ; Clindamycin 450mg 8‐hourly for 7 days.
Document Ref
October 2011
Page 10 of 11
Cellulitis
1. Habif TP, ed. Clinical Dermatology. 5th ed. Philadelphia, Pa: Mosby Elsevier; 2009; chap 9.
2. Mandell GL, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases. 7th ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2009:chap
90.
3. Jones,V. & Harding,G. (2003). Wound Management A Constructive Approach. Australia: 3M HealthCare.
th
4. Therapeutic Guidelines - Antibiotic, Skin and soft tissue infections. 13 Edition, 2006, pages 269-98.
5. eMIMS. [eMIMS on Clinical Information Access Online website] 2008; Available from: http://www.use.hcn.com.au/html/wah/godirect.html
6. Treatment of infections in "Hospital in the Home" programs, Hospital in the Home IV antibiotic service : RPH Microbiology and Infectious Diseases, Departments &
Services, Servio Online, SMAHS Online (Intranet).
7. The Royal College of Pathologists Australasia, RCPA Manual
http://www.rcpamanual.edu.au/sections/clinicalproblem.asp?s=25&i=109
[The
Royal
College
of
Pathologists
of
Australasia]
2004;
Available
from:
8. Swartz M. Cellulitis. The New England Journal of Medicine. 2004;350:904-12.
9. 2. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections. [Infectious Diseases Society of America] 2005; Available from:
http://www.idsociety.org
10. A randomized-controlled trial comparing cadexomer iodine and nanocrystalline silver on the healing of leg ulcers. April 26, 2010 Wound Rep Reg (2010) 18 359–367 _c
2010 by the Wound Healing Society. N Newall, c Karville etal
http://www.silverchain.org.au/assets/files/RA0064-Angior-Main-RCT-results-paper-WRR.pdf
Cellulitis
Validated by :Mr David Lyle Clinical Governance Manager the Bethanie Group( RN)
Mr Louis Anastas Clinical Pharmacist Osborne Park Pharmacy
Dr Julius Tan General Practitioner
Document Ref
October 2011
Page 11 of 11